Does Health Insurance Cover TMJ

Navigating the path to relief from TMJ disorder and seeking appropriate care can be incredibly frustrating.

Figuring out how to get your treatments covered by insurance demands significant time and energy.

Dealing with insurance processes can be stressful, especially when you’re simply seeking relief without breaking the bank.

TMJ disorder
TMJ disorder: Photo source (Legit.ng)

Why Is It So Hard To Get Insurance Coverage For TMJ?

The jurisdiction over temporomandibular joint (TMJ) health has sparked debates between dental and medical communities.

Dentists focus on oral health, while medical doctors understand TMJ as part of a larger system.

The absence of specialized practitioners complicates insurance coverage.

TMJ treatment pathways vary, leading to challenges in insurance claims.

Historically, TMJ disorder lacked recognition, making insurance coverage difficult.

Recently, major insurers acknowledge TMJ as a common disorder, easing coverage for the approximately 12% of the population affected.

How To Get TMJ Covered By Insurance

Dental insurance rarely covers TMJ disorder treatment, but major medical insurers might in state-mandated cases.

Finding covered care is challenging even for fully insured individuals.

Understanding your coverage requires checking your insurance plan guidebook or contacting their support.

Each plan varies in TMJ treatment coverage, including devices, therapy, chiropractic, or surgery.

Insurers assess specific criteria before authorizing upfront coverage or reimbursing a claim.

1. Diagnosis

Often, an insurance company will require a diagnosis of any health condition before they cover treatment.

Most primary care doctors can diagnose TMJ, but not many have the proper training or tools to treat the condition.

You’ll want to get your diagnosis from either a doctor or dentist who can refer you to proper care or from a specialist who will treat your jaw pain.

2. Seriousness Of Condition

Insurance companies don’t like to frivolously spend their money.

They’ll often look to the doctors to indicate treatment needed based on the severity of the condition.

If your TMJ disorder has a relatively low impact on your life, insurance may not find treatment necessary.

3. Necessity Of Treatment

The necessity of treatment for TMJ depends on the seriousness of your condition.

Health insurance covers what doctors consider “medically necessary,” usually after a diagnosis.

Preventative treatments might be considered in some cases.

Insurance can pay in full or partially upfront or reimburse your expenses, depending on your plan.

There might be deductibles, and it’s crucial to get reimbursement agreements in writing and ensure treatment approval before payment to avoid surprises.

Alternatives To Health Insurance For TMJ

If your insurance lacks sufficient TMJ coverage, consider alternatives to ease the financial burden.

Health savings accounts (HSAs) and flexible spending accounts (FSAs) allow pre-tax savings for medical expenses.

HSAs are for high-deductible plans and can roll over funds annually, while FSAs may have stricter yearly spending limits.

These accounts are beneficial for chronic conditions like TMJ, providing long-term financial assistance for ongoing treatments.

Investigate these options to manage TMJ-related costs effectively.

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